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Mississippi Nursing Degree Programs
Accreditation Standards Procedure Manual
Effective October 17, 2019
Office of Academic and Student Affairs
3825 Ridgewood Road ~ Jackson, Mississippi 39211
601.432.6501 http://www.mississippi.edu/nursing/
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
TABLE OF CONTENTS
I. INTRODUCTION ............................................................................................. 3 Authority ...................................................................................................................................3
Purposes for Accreditation ........................................................................................................3
II. STANDARDS FOR ACCREDITATION ..................................................................3
STANDARD I. Mission and Administrative Organization ....................................................4
STANDARD II. Faculty and Staff...........................................................................................5
STANDARD III. Students ........................................................................................................7
STANDARD IV. Curriculum ...................................................................................................8
STANDARD V. Resources .....................................................................................................11
STANDARD VI. Outcomes .....................................................................................................11
III. RULES AND REGULATIONS FOR ACCREDITATION ........................... 11
Confidentiality ..........................................................................................................................12
Conflict of Interest ....................................................................................................................12
Types of Accreditation ..............................................................................................................12
Accreditation Process................................................................................................................14
IV. CHANGES IN EXISTING NURSING PROGRAMS/REPORTS ...................18
V. CRITERIA FOR ESTABLISHING A PROGRAM OF
PROFESSIONAL NURSING IN THE STATE OF MISSISSIPPI .............. 19
Stage I – Declaration of Intent/Need ........................................................................................19
Stage II – Qualify for Initial Accreditation ...............................................................................20
State III – Qualify for Full Accreditation .................................................................................24
Roles, Responsibilities, and Procedures ...................................................................................26
VI. REVISION DATES ............................................................................................ 28
APPENDICES ..............................................................................................................................29
GLOSSARY ..................................................................................................................................46
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
I. INTRODUCTION
A. Authority:
The revised "Accreditation Standards and Rules and Regulations for Mississippi
Nursing Degree Programs" are promulgated in accordance with (a) and (b), Miss.
Code (2008 Supp.) §37-129-1, et seq., which empowers and requires the Board of
Trustees of State Institutions of Higher Learning (the Board) to:
a) Establish by rules and regulations and promulgate uniform standards for
accreditation of schools of nursing in the state of Mississippi (1) in so far as
concerns the eligibility of graduates of such schools to take the examination
prescribed by law to become registered nurses authorized to practice the
profession of nursing as registered nurses in Mississippi, and (2) in so far as
concerns student nurses attending such schools being eligible to participate in any
student nurse scholarship program or other program of assistance now existing or
hereafter established by legislative enactment;
b) Issue to such schools of nursing upon an annual basis certificates of accreditation
as may be proper under such standards.
The Board, in recognizing that each unit in nursing offering nursing degree
programs has individual characteristics and goals, maintains that each shall
implement its own philosophy, purposes, and objectives. All programs in nursing
shall be based on sound educational principles under the guidance of a competent
faculty. The total program of nursing education shall meet the required standards
of accreditation as prescribed by the Board. Mississippi nursing schools (units in
nursing) should prepare students for nursing careers according to the type of
program that they offer. Rigid conformity to a specific and fixed curriculum is not
expected. Rather, the Board approves programs which are of superior caliber and
encourages creative and intelligent experimentation based on sound principles.
B. Purposes for Accreditation:
The purposes for accreditation of nursing education programs are:
(1) To set minimum standards for educational programs preparing nurses for practice
at all levels.
(2) To grant official recognition to new and established nursing education programs
that meet established standards.
(3) To ensure that graduates are prepared for safe, current, and appropriate scope of
practice relative to type of nursing education program and state laws governing
nursing.
(4) To encourage continuing program improvement through assessment, evaluation
and consultation.
II. STANDARDS FOR ACCREDITATION
All Nursing Education Programs must be located in or otherwise accredited as a post-
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
secondary educational institution with appropriate local and state governing boards’
approval to grant the appropriate degree or certificate. The educational institution must be
regionally accredited by the Southern Association of Colleges and Schools, Commission
on Colleges (SACS-COC).
All Nursing Education Programs must be accredited by a national nursing education
accrediting body approved by the United States Department of Education. National
accreditation ensures the quality and integrity of associate, baccalaureate, graduate and
doctoral degree nursing programs and holds nursing programs accountable to the
educational community, the nursing profession and the public. The accrediting bodies for
professional nursing education are the Commission on Collegiate Nursing Education
(CCNE) and the Accreditation Commission for Education in Nursing (ACEN). The
accrediting body for the nurse anesthesia programs is the Council on Accreditation of
Nurse Anesthesia Educational Programs (COA).
STANDARD I. Mission and Administrative Organization
1. National Standards
a. ACEN
Standard 1: Mission and Administrative Capacity
Standard 4: Curriculum
b. CCNE
Standard I: Program Quality: Mission and Governance
Standard II: Program Quality: Institutional Commitment and Resources
2. State Specific Requirements
a. Minimum education requirements for administrators are:
Associate degree programs – Graduate degree in nursing from a regionally
accredited institution.
Baccalaureate and higher degree programs – Doctoral degree in nursing; or a
graduate degree in nursing and a doctoral degree from a regionally accredited
institution.
b. All – unencumbered current license to practice in Mississippi.
c. All – satisfy a criminal history background check.
d. All – minimum of five (5) years of experience in a registered nursing education
program to include teaching, curriculum development and program evaluation.
e. All – leadership, management, and/or administrative experience in the discipline
of nursing.
f. All – a minimum of two years of clinical experience.
Required Documentation for Nurse Administrator
1. Transcripts (degrees; certifications)
2. Curriculum Vitae
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
3. Criminal History Background Check or signed affidavit
4. RN License
STANDARD II. Faculty and Staff
1. National Standards
a. ACEN
Standard 1: Mission and Administrative Capacity
Standard 2: Faculty and Staff
b. CCNE
Standard I: Program Quality: Mission and Governance
Standard II: Program Quality: Institutional Commitment and Resources
Standard IV: Program Effectiveness: Assessment and Achievement of Program
Outcomes
2. State Specific Requirements
a. All nursing faculty (full-time, part-time and adjunct) in nursing programs must
have a minimum of a graduate degree in nursing from a regionally accredited
institution and a minimum of one year of clinical experience as a registered nurse.
b. All nursing faculty (full-time, part-time and adjunct) must hold an unencumbered
license to practice in Mississippi.
c. All nursing faculty (full-time, part-time and adjunct) must satisfy a criminal
history background check.
d. All full-time nursing faculty must implement an annual professional development
plan, which includes ten (10) contact hours of continuing education each
academic year. Part-time and adjunct faculty must satisfy the professional
development requirement in accordance with their designated FTE.
e. The majority of nursing faculty in graduate nursing programs must also have
doctoral degrees from regionally accredited institutions.
f. Preceptors shall be academically/experientially prepared at or beyond the level for
which the preceptor service is rendered and shall have a minimum of one year
experience.
g. All non-nurse faculty (interdisciplinary) must be academically/experientially
prepared at or beyond the level for which teaching/clinical service is rendered,
shall have a minimum of one year experience in the related field of study and
satisfy a criminal history background check.
Required Documentation for Faculty
1. Transcripts (degrees; certifications)
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
2. Curriculum Vitae
3. R.N. License & Advanced Practice RN License, if appropriate
4. Certification (i.e. Role Specific – FNP, PMHNP, GNP, etc.)
5. Criminal History Background Check or signed affidavit
6. Annual Professional Development Plan
7. Validation of 10 contact hours by academic year
8. Faculty Exception supporting documentation
Required Documentation for Preceptors
1. Education verification
2. Clinical experience verification
3. R.N. License & Advanced Practice RN License, if appropriate
4. Certification (i.e. Role Specific – FNP, PMHNP, GNP, etc.)
Faculty Exception to Educational Requirement (2.a, 2.b, 2.c & 2.d):
Exceptions may be granted by the Director of Nursing Education within the following
parameters (APPENDIX A).
1. Exception faculty must be continuously enrolled in a graduate degree nursing
program. Official verification of course enrollment should be submitted to the
school of nursing at the beginning of each semester, and an official transcript
indicating course completion to the school of nursing at the end of each semester.
New faculty exception requests must also include an official acceptance letter
from the School of Nursing where the faculty is enrolled.
Request for Faculty Exception must be submitted to the Director of Nursing
Education two weeks prior to the beginning of each semester (Fall, Spring &
Summer), or prior to hire date within a given semester.
2. Faculty enrolled in an RN-MSN program must have completed a minimum of
fifty percent of total credit hours of program of study before consideration will
be given for approval of faculty exception. A letter is required from the school of
nursing where the faculty is enrolled validating fifty percent completion of credit
hours of program of study (in addition to copies of current official transcripts on
file at school of nursing).
3. The maximum time allowed to complete the graduate program is three years.
4. Faculty exceptions are limited to a total of 15 percent of the teaching faculty,
excluding the nurse administrator (Dean or Director), OR one exception for
programs with six or fewer teaching faculty. Faculty that fall under the exception
clause must meet all other state specific faculty requirements.
Licensure (2.b)
Faculty with clinical teaching responsibilities (precepted or directed) in other states
must hold an unencumbered registered nurse (R.N.) license recognized in that state,
in addition to Mississippi.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
Preceptors (2.f) & Non-Nurse Faculty (2.g) Requirements
The school of nursing will maintain documentation validating non-nurse faculty
(interdisciplinary) and preceptors’ education, clinical experience, and licensure (if
appropriate). Types of documentation may include a letter from the clinical agency or
individual forms signed by preceptor and clinical agency, current copy of
RN/APRN/other professional license and certifications.
Annual Professional Development Plan (2.d)
All full-time faculty must implement an annual professional development plan that
may include personal and professional goals, actions, and activities, and evaluation
for goal attainment. The plan must have been approved by the administrator of the
nursing program or designee AND must total a minimum of ten contact hours per
academic year. The ten contact hours may include a combination of course work,
professional educational presentations, and/or attendance at continuing education
offerings. One semester credit hour of academic course work equates to 15 contact
hours.
Part-time and adjunct faculty must satisfy the professional development requirement
in accordance with their designated FTE and as required by the institution.
Method of validating contact hours is determined by the nurse administrator or
designee (examples: CEU certificates, sign-in list, agendas for presenters, etc.).
STANDARD III. Students
1. National Standards
a. ACEN
Standard 3: Students
b. CCNE
Standard I: Program Quality: Mission and Governance
2. State Specific Requirements
a. Associate Degree Nursing Programs.
Minimum admission criteria for associate degree nursing programs are as follows:
1. An ACT composite score of 18 and a 2.0 GPA.
2. Students without the required ACT composite score must have completed a
minimum of 12 semester hours in the nursing major, including Anatomy and
Physiology, with at least a grade of “C” and have a minimum 2.5 GPA
before being admitted.
3. All students must satisfy a criminal history background check.
4. Each school is permitted an allowance of 10 percent of the previous fall’s
nursing program admission for high risk students who do not meet the criteria.
b. Bachelor Degree Nursing Programs.
Minimum admission criteria for bachelor degree nursing programs are as
follows:
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
1. An ACT composite score of 21. Students with the required ACT composite
score must also have at least a grade of “C” in each prerequisite course to the
nursing major and a 2.0 GPA.
2. Students without the required ACT composite score must complete all the
course prerequisites to the nursing major with at least a grade of “C” and a
GPA of 2.5.
3. Student with a registered nurse (R.N.) license may enter without an ACT by
completing all the course prerequisites to the nursing major with at least a
grade of “C” and have a GPA of 2.0.
4. Baccalaureate nursing programs in private educational institutions may
establish admission criteria which support the goals and aims of t their
institution.
5. All students must satisfy a criminal history background check.
6. Each school is permitted an allowance of 10 percent of the previous fall’s
nursing program admission for high risk students who do not meet the criteria.
c. Graduate Degree Nursing Programs.
Minimum admission criteria for graduate degree nursing programs (MSN &
DNP) are as follows:
1. An analytic score of at least 3.0 on the Graduate Records Exam (GRE).
2. Minimum 3.0 GPA for the most recent nursing degree.
3. Private educational institutions may establish admission criteria which support
the goals and aims of their institution.
4. All students must hold an unencumbered registered nursing (R.N.) license to
practice in the state in which the student will perform clinical.
5. All students must satisfy a criminal history background check.
Graduate Degree Nursing Programs with Post-Graduate APRN Programs
Post-Graduate APRN programs will adhere to the admission criteria requirements of
the university and nursing program, and national nursing accreditation standards.
Required Documentation for Students
1. Official ACT scores
2. Transcripts – validating GPA
3. Official GRE scores
4. RN/APRN license and certification
5. Criminal history background check
High Risk Students
High risk students are those who do not meet one or more program specific minimum
admission requirements. Each school of nursing will maintain a list of the previous
fall admission numbers and numbers of high risk students admitted.
STANDARD IV. Curriculum
1. National Standards
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
a. ACEN
Standard 4: Curriculum
b. CCNE
Standard II: Program Quality: Institutional Commitment and Resources
Standard III: Program Quality: Curriculum and Teaching-Learning Practices
2. State Specific Requirements
a. Undergraduate student-to-faculty ratios must be:
1.No more than 15 to 1 for total enrollment.
2.No more than 10 to 1 for clinical laboratory courses that require direct
supervision.
3.No more than 15 to 1 for those courses that do not require direct
supervision (i.e. precepted experiences).
b. Graduate student-to-faculty ratios must be:
1. No more than 15 to 1 for total enrollment.
2. No more than 15 to 1 in graduate clinical courses.
3. No more than 2 to 1 for advanced practice clinical courses that
require direct supervision.
4. No more than 6 to 1 for advanced practice clinical courses that do
not require direct supervision (i.e. precepted experiences).
c. Undergraduate Simulation Clinical Hours:
1. 25% or less of traditional clinical hours substituted with simulation
clinical hours in each individual clinical course does not require
approval.
2. 26% up to 50% of traditional clinical hours substituted with
simulation clinical hours in each individual clinical course requires
approval.
3. No more than 50% of traditional clinical hours can be substituted
with simulation clinical hours in each individual clinical course.
Required Documentation
Validation of student-to-faculty ratios must be maintained in the school of nursing each
semester.
1. Total enrollment and number of faculty.
2. Copy of all clinical rotation schedules for supervised student clinical groups.
3. Copy of all precepted course rosters and faculty.
Request for 50% Simulation Clinical Hours (26% up to 50%)
NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study
Replacing Clinical Hours with Simulation in Prelicensure Nursing Education (Journal of
Nursing Regulation, 5(2), July 2014 Supplement) findings “provides substantial evidence
that up to 50% simulation can be effectively substituted for traditional clinical experience
in all prelicensure core nursing courses under conditions comparable to those described in
the study” (p. S38).
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
State of Mississippi approved registered nursing programs may have up to 25% of
traditional clinical hours substituted with simulation clinical hours in each individual
clinical course. Simulation clinical hours must not exceed a 1:1 ratio for substitution of
traditional clinical hours, and no more than a 10:1 student-to-faculty ratio for simulation
clinical experiences. Schools of nursing may request approval of 26% and up to 50% of
simulation clinical hours substituted for traditional clinical hours in each individual
clinical course by submitting electronically through the secure site Deans and Directors
Login http://www.mississippi.edu/nursing/login/ the Request for Simulation Clinical
Hours and Focused Report documenting compliance with requirements for approval. The
request and report must be submitted three months prior to the proposed implementation
date. A focused-site visit (one day) will be scheduled to validate compliance with
requirements. All travel expenses will be reimbursed directly to the state site visitors by
IHL at the current state rate (travel, lodging and meals). IHL/Office of Finance and
Administration will send an invoice to the school of nursing to reimburse IHL.
Required Documentation for Approval of Simulation Clinical Hours
1. Request for Simulation Clinical Hours and Focused Report (Electronic
Submission/Secure Site)
a. Request (Appendix B example)
b. Focused Report
i. Simulation Guidelines (Appendix C example)
ii. Simulation Faculty Preparation (Appendix D example)
iii. Program Preparation (Appendix E example)
iv. Confirmation
2. Focused Site Visit Schedule
a. Meet with Nurse Administrator
b. Meet with Simulation Director/Coordinator
c. Meet with Faculty teaching in clinical courses with simulation hours
d. Tour of Simulation Lab/Facility
3. Documents Available for On-Site Review
a. Accreditation Status (IHL, ACEN, CCNE, COA, SACS-COC & Other)
b. Nurse Administrator File(s)
c. Simulation Director/Coordinator File
d. Faculty Files (clinical courses)
e. Clinical Courses: Syllabi, Course Schedules, & Evaluation Tools
f. Simulation Policies, Procedures, and Guidelines
v. Nursing Student Handbook
vi. Nursing Faculty Handbook
g. NCSBN Simulation Guidelines – Evidence
h. NCSBN Faculty Preparation Checklist – Evidence
i. NCSBN Program Preparation Checklist – Evidence
j. Additional documents upon request
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
STANDARD V. Resources
1. National Standards
a. ACEN
Standard 1: Mission and Administrative Capacity
Standard 5. Resources
a. CCNE
Standard II: Program Quality: Institutional Commitment and Resources
2. State Specific Requirements
None
STANDARD VI. Outcomes
1. National Standards
a. ACEN
Standard 6: Outcomes
b. CCNE
Standard IV: Program Effectiveness: Assessment and Achievement of Program
Outcomes
2. State Specific Requirements
a. NCLEX Pass Rates: Annual NCLEX pass rates for all test takers (1st and repeat)
will be at 80 percent or above over a three-year period.
b. Degree Completion Rates: Expected levels of achievement for program
completion are determined by the faculty and reflect program demographics,
academic progression, program history, best practices, and will be within 150
percent of the stated program length over a three-year period.
b. Certification Pass Rates:
1. Annual nurse practitioner certification exam pass rates for all test takers (1st and
repeat) will be at 80 percent or above over a three-year period.
2. Annual nurse anesthesia certification exam pass rates for all test takers (1st and
repeat) will be at 80% or above over a three-year period.
Required Documentation
1. Maintain official copies of the Mississippi Board of Nursing NCLEX-RN®
reports for a three (3) year period.
2. Calculation of NCLEX-RN® pass rates for the calendar year will be sent to the
Director of Nursing Education in January, following receipt of the December
cumulative report from the Board of Nursing (APPENDIX F).
3. Each school of nursing will enter the program benchmark and their annual
degree completion rate with data, and nurse practitioner/nurse anesthesia
certification rate with data in the annual report submitted by October 15
(APPENDIX G; APPENDIX H).
III. RULES AND REGULATIONS FOR ACCREDITATION
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
A. CONFIDENTIALITY OF ACCREDITATION INFORMATION
All data, observations, conversations, conclusions, reports, and minutes relating to
accrediting activities are CONFIDENTIAL. Acceptance of an invitation to be a site
visitor constitutes a contractual agreement to safeguard the confidentiality of
accrediting data. Therefore, observations made during the visit, in the self-evaluation
report, the site visitors’ report, correspondence between the unit in nursing and the
Board, as well as discussions and recommendations of the Accreditation Review and
Evaluation Committee, are all confidential and privileged communications.
It is essential not to divulge any information from these sources, to avoid leaving
where they may be read by others, and to refrain from discussing findings during the
visiting experience with colleagues or others in one’s own institution or elsewhere.
Reports concerning statistical, personnel, and program data, as well as other materials
required by the Board, shall be submitted when requested.
B. CONFLICT OF INTEREST
All individuals involved in any aspect of state accreditation activities are expected to
recognize relationships in which they may have a potential conflict of interest, and to
remove themselves from deliberations concerning institutions and programs when
such conflicts exist. Conflicts of interest include, but are not limited to, current or
former employment by the institution whose program is being evaluated, current
employment in an institution that is located in close proximity to or in direct
competition with the institution whose program is being evaluated, and/or attended
the institution whose program is being evaluated.
C. TYPES OF ACCREDITATION
The Board shall grant to a state nursing degree program one of the following types of
accreditation, based on the evaluation of annual reports documenting compliance with
the state nursing accreditation standards:
1. Initial Accreditation
a. Granted when the program is in compliance with all standards for a new
program. Permission is granted to admit students and the next review is in the
final semester of the first class in conjunction with the initial national visit.
b. Denied when the program does not meet all standards for a new program. The
program may reapply at any time.
2. Continuing Accreditation
a. Full Accreditation. National accreditation and state specific requirements
have been met.
b. Accreditation with Conditions. National standards and/or state specific
requirements have not been fully met.
(1) National Accreditation. When one or more national standards are not met,
the program’s state accreditation status will be the same as that
designated by the national accrediting body. The program must
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
satisfactorily address the area(s) of concern/deficiency and demonstrate
compliance within the designated time frame set forth by the national
accrediting body.
(2) State Specific Requirements. When one or more state specific
requirements are not met, the program must satisfactorily address the
area(s) of concern/deficiency through the development of a performance
improvement plan. Upon program notification of noncompliance, the
state specific requirement must be achieved within the time frame set
forth by the Director of Nursing Education, Office of Academic and
Student Affairs.
Performance Improvement Plan & Progress Report
If the standard(s) is/are not met, the program will submit a performance
improvement plan (PIP) by June 30 following official notification after
the annual Board meeting in May. If the standard(s) is/are still not met by
the next year, the program will submit a PIP progress report by June 30
following official notification after the annual Board meeting in May. If
the standard(s) is/are not met following two full years on a PIP, a
recommendation of Accreditation with Statement of Warning will be
made by IHL Director of Nursing Education, Office of Academic and
Student Affairs, to the Board of Trustees.
c. Accreditation with Statement of Warning. The performance improvement
plan has not resulted in program compliance with standard(s). A follow up
focused visit, by members selected by the IHL Office of Academic and
Students Affairs’ Nursing Education Unit, is scheduled within three months of
statement of warning. A final performance improvement plan is due within 12
months of the issue of the warning that addresses the recommendations made
by the state site visit team.
3. Accreditation Denied/Withdrawn. If a program is not in compliance with
national standards and/or state specific requirements as specified in the time
frame identified under Accreditation with Statement of Warning, the
recommendation for the withdrawal of accreditation will be made by the IHL
Director of Nursing Education, Office of Academic and Student Affairs, to the
Board of Trustees.
Closure of Nursing Education Program and Storage of Records
If a nursing education program is closed due to withdrawal of the Board of
Trustees’ approval, provision will be made for:
a. Maintenance of the standards for nursing education during the transition to
closure.
b. Placement for students who have not completed the program.
c. Arrangement for the secure storage and access to academic records and
transcripts.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
D. ACCREDITATION PROCESS
The national accreditation process will be conducted according to the policies and
procedures outlined by the accrediting body.
1. State Accreditation. State accreditation site visits will be conducted in
conjunction with national accreditation site visits. Each school of nursing will
submit a copy of the notification letter from the accrediting body regarding the
date of the site visit and a copy of the site visit schedule to the Director of Nursing
Education.
Each school of nursing will notify the national accrediting body that a state
accreditation site visit will be made in conjunction with the national site visit.
Information should include the authority of the Mississippi Board of Trustees of
State Institutions of Higher Learning (the Board), which is empowered and
required by state statute to: (a) establish by rules and regulations and promulgate
uniform standards for accreditation of schools of nursing in the state of
Mississippi; and (2) issue to such schools of nursing upon an annual basis
certification of accreditation as may be proper under such standards.
2. Self-Review and Self-Study Report. Each school of nursing must submit three
(3) to five (5) hard and electronic copies of the self-study report to the Director of
Nursing Education in accordance with the time frame required by national
accrediting body.
3. Peer Evaluation Review Team. The selection of a Peer Evaluation Review
Team (PERT) for each state accreditation visit is the responsibility of the Director
of Nursing Education in collaboration with the Chair of the Accreditation Review
and Evaluation Committee (AREC).
a. Composition of the PERT will consist of two or more visitors from the
nursing education community, with one member appointed as Chair.
b. PERT members will be selected based on experience and professional
knowledge of the program that is being evaluated. However, this does not
preclude the dean/director/faculty of an associate degree program
evaluating a baccalaureate or higher degree program, and the dean/faculty
of baccalaureate or higher degree program evaluating an associate degree
program.
c. PERT members who may have a conflict of interest regarding any issue
pertaining to the school of nursing, must recuse themselves from the team
and a new member(s) appointed.
4. Responsibilities of the Director of Nursing Education.
The Director of Nursing Education is responsible for performing the following
duties:
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
a. Plan with each administrator of the unit in nursing the accreditation site
visit schedule for state site visitors Visits will be in conjunction with the
national accreditation site visit.
b. Select two or more state site visitors and a chair, in collaboration with the
chair of the Accreditation Review and Evaluation Committee (AREC).
c. Request that the unit in nursing’s self-study, along with any other
materials, be submitted to the Director of Nursing Education at least six
weeks prior to the scheduled visit.
d. Submit the following to the school:
i. List of materials needed to document and supplement the self-
study report.
ii. Names of prospective PERT members.
e. Submit the following to the PERT:
i. Self-study and any other appropriate state accreditation materials.
ii. College catalog and/or electronic link.
iii. Any other reports submitted by the nursing unit.
iv. State travel vouchers and any other Board required documentation
and/or forms.
f. Participate on the State Accreditation Team for initial and continuing
ACEN, CCNE and COA visits.
g. The Director of Nursing Education will send the preliminary site visit
report back to the nurse administrator of the education unit in nursing for
review and correction of any errors in factual data. When the report is
returned to the Director of Nursing Education, the nurse administrator’s
response will be appended to the report. .
h. The Director of Nursing Education will discuss the site visit report to the
Chair of the Accreditation Review and Evaluation Committee (AREC) of
the Mississippi Deans and Directors of Schools of Nursing (MCDDSN) at
least two weeks in advance of the January or June meeting.
i. The Director of Nursing Education will hold the site visit report and
accreditation status recommendation pending the final report from the
national accrediting body.
j. The Director of Nursing Education, within the Office of Academic and
Students Affairs, will send a letter of notification regarding the School of
Nursing’s accreditation status to the College/University President and
Dean/Director of the School of Nursing.
5. Responsibilities of the School of Nursing.
a. Notify the Director of Nursing Education upon receipt of letter of
confirmation of national site visit dates.
b. Send three (3) to five (5) copies of the self-study report (hard and
electronic), catalog (hard or electronic), and other material to the Director
of Nursing Education at the same time the information is sent to the
national nursing accrediting body. Ensure all provided electronic links are
accessible.
c. Additional material available during state site visit should include:
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
i. Nurse Administrator(s) files(s) to include: transcripts,
certifications, curriculum vita, validation of Mississippi RN license
(other states if applicable), and criminal history background check
or signed affidavit.
ii. Faculty files to include: transcripts, certifications, curriculum vita,
validation of Mississippi RN and APRN license (other states if
applicable), criminal history background check or signed affidavit,
and an annual professional development plan to include 10 contact
hours by academic year. Faculty who have been granted a “Faculty
Exception” should have additional documentation on file (refer to
Faculty Exception to Educational Requirement, p. 6).
iii. Official student records to verify that standards have been met
(sufficient quantity from each program will be determined by the
PERT). Based on program type, student files must include: GPA,
ACT, transcripts, GRE, license and certification, and a criminal
history background check.
iv. Faculty/Student clinical rotation schedules.
d. Reserve hotel rooms for PERT six weeks prior to site visit. Notify each
PERT member by email regarding the reservation confirmation number.
e. Submit a tentative agenda for the site visit to the Director of Nursing
Education.
f. Provide directions to the school of nursing to PERT members.
g. Submit copies of any further correspondences from the national
accrediting body to the Director of Nursing Education following the site
visit.
h. Submit a copy of the final accreditation status report received from the
national accrediting body to the Director of Nursing Education.
i. Send the Director of Nursing Education the name, address, phone/fax
number, and email address of the contact person to send the invoice for
reimbursement for state site visitors travel expenses. All travel expenses
will be reimbursed directly to the state site visitors by IHL at the current
state rate (travel, lodging, and meals). IHL/Office of Finance and
Administration will send an invoice to the school of nursing to reimburse
IHL.
6. Responsibilities of the Peer Evaluation Review Team (PERT).
Although one visitor is designated as the chair, visitors work together closely
and share responsibility for all aspects of the visit.
Each PERT member is expected to be knowledgeable about the accreditation
process and the Mississippi Nursing Degree Programs Accreditation Standards
and Procedure Manual.
In addition, it is important for each PERT member to be thoroughly conversant
with the content of the self-study report, any other evaluative reports, and for
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
materials submitted by the unit in nursing in advance. Any information
needed for clarification should be requested from the IHL Director of Nursing.
It is advisable for the PERT members to allocate time prior to the visit to
discuss the self-study report and to outline the procedures to be followed
during the visit.
Objectivity is of prime importance during the evaluation process. Each aspect
of the program must be evaluated only in terms of the evidence presented as it
relates to the requirements for accreditation.
The PERT members’ role during the accreditation visit is to clarify, amplify,
and verify the information submitted by the unit in nursing in relation to the
state standards for accreditation.
The chair of the PERT should assume the following responsibilities:
a. Act as official spokesperson for the PERT.
b. Coordinate planning and allocate responsibilities for various activities to
assure optimum utilization of team members and at the same time assure
adequate coverage of all areas during the visit.
c. Assure that the site visit report supplements and complements the program’s
self-study report and that evidence presented relates to the program’s
objectives and state standards.
d. Participate in a final conference with the administrator of the unit in nursing
and any others that the administrator desires to have present. Corrections of
any errors in the factual data can be made at this time by the PERT chair.
The PERT members should assume the following responsibilities:
a. Conduct a site visit of the nursing program to verify, clarify, and amplify the
self-study prepared by the unit in nursing so that the evaluators of reports and
site visit results will have a clear and complete picture of the program(s) in
nursing.
b. Evaluate each program on the basis of information that is received from the
school’s self study, progress report, the site visitors’ report, and the school
catalog and other materials submitted by the school.
c. Prepare a report that includes the verification of data, documentary statements,
and additional descriptive material essential to a clear and concise picture of
state specific requirements.
NOTE: PERT members should not request materials from the college for
personal use -- only to supplement the self-study.
7. Responsibilities of the Accreditation Review and Evaluation Committee
(AREC)
a. The AREC will meet in January and June for review of state accreditation site
visit reports and recommendations for each school of nursing, with additional
meetings scheduled as needed.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
b. The AREC will be informed of the outcome of the site visit from the chair of
the AREC and Director of Nursing Education.
c. The AREC will review the accreditation procedure manual in February of each
year.
IV. CHANGES IN EXISTING NURSING PROGRAMS/REPORTS
Schools of Nursing must submit to the IHL Director of Nursing Education a copy of any
report (substantive, etc.) sent and received from the national nursing accrediting body
(ACEN, CCNE or COA). Substantive change requests must include correspondences from
ACEN, CCNE, COA and the Southern Association of Colleges and Schools – Commission
on Colleges (SACS-COC). Additionally, the following information will be sent to the
Director of Nursing Education:
Action Requirement
Annual Report Complete annual report forms by October 15
Change in ownership Notification letter
Change in directors/deans Notification letter
Markedly altering the
curriculum
Detailed description with review by the Director of Nursing
Education and AREC
Adding a new teaching site Detailed description of educational, financial, operational,
management, and physical resources to offer program with
review by Director of Nursing Education and AREC
National accreditation Copy of notification
Change in accreditation status Copy of notification (Institutional or Program)
Decision made to discontinue
the program
The Board shall be notified in writing of the intention of the
controlling institution. If the remaining students continue in
the program, adequate faculty and educational standards
shall be maintained until the last student has completed the
program. This date shall be the official closing date of the
nursing program. Disposition of all students' permanent
transcripts and final records shall be made in accordance
with institutional policy. A representative of the Board shall
visit the nursing program and assist in making arrangements
for proper closure and, if necessary, for the transfer of
students.
An institution desiring to reopen an educational unit in
nursing or a nursing program shall reapply for approval of a
newly planned program.
Request of information
Information requested by Director of Nursing Education
The Director of Nursing Education will report to MS Council of Deans and Directors any
notification of and request for substantive changes.
The Director of Nursing Education will complete a yearly program evaluation on each school of
nursing based on annual report data submitted by the school, accreditation site visit reports (state
and national), and other pertinent information.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
The Director of Nursing Education will submit a report to the Board annually that will include
selected data from the Schools of Nursing Annual Report data to include:
1. Admission, enrollment and graduation data 6. Graduation data by program and degree
2. NCLEX-RN® pass rates 7. Graduate program enrollment by clinical practice role
3. Student/Faculty ratios 8. Nurse practitioner and nurse anesthetist certification
rates
4. Faculty vacancies 9. National accreditation status and schedule
5. Degree completion rates 10. Other data
The IHL Director of Nursing will prepare recommendations for approval of annual accreditation
status for schools of nursing to the Board during the annual meeting in May.
V. CRITERIA FOR ESTABLISHING A PROGRAM OF PROFESSIONAL
NURSING IN THE STATE OF MISSISSIPPI
The three stages to be completed in the development of a new professional nursing program
in Mississippi are as follows:
STAGE I - DECLARATION OF INTENT/NEED
Process
1.1 An institution considering the establishment of a state-accredited unit in nursing shall
request a meeting with the Director of Nursing Education to discuss procedure and
requirements for submission of Stage I documentation.
1.2 The institution submits the application for Stage I and the required documentation to
the Director of Nursing Education (APPENDIX I). Upon receipt of the institution’s
completed Stage I application, the Director of Nursing Education carries out the
following:
1.2.1 Submit to Deans and Directors for feedback.
1.2.2 Submits information to the Office of Academic and Student Affairs (OASA)
to determine that all required information is included as specified in the
Stage I criteria.
1.2.3 Facilitates the process for public comment.
1.2.4 Collaborates with OASA to submit a summary of the Declaration of Intent
and public comment with a recommendation of either approval or
disapproval to the IHL Board of Trustees.
1.2.5 The IHL Board of Trustees issues the decision to either approve or disapprove
the OASA recommendation for Stage I.
1.2.6 Sends a letter to the institution informing them of the Board of Trustees’
decision explaining the following:
Decision of approval - allows the institution to begin work on Stage II.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
Decision of disapproval - provides a rationale for the decision. The institution
may revise the application and resubmit it to the Board of Trustees at a later
date or abandon its intention to establish a nursing program.
Criteria
The application for Stage I should include the following information:
1.2 Approval from the institution’s governing/coordinating board.
1.3 Establishment of a local advisory committee to provide input into a nursing program,
which includes representation from nursing education, nursing practice, health care
facilities, educational agencies, and the community; inclusion of evidence of
advisory committee of local stakeholders involvement in the planning process.
1.4 Evidence of obtaining professional advice from qualified nurse educator(s) who
is/are involved in administering an accredited nursing program(s) and/or an approved
national nursing accrediting body.
1.5 Substantive evidence of need for establishment of a new program of nursing to
include qualitative and quantitative data from the Community of Interest (COI) and
key stakeholders such as local educational institutions, community organizations,
local health care agencies, and other appropriate sources/entities.
1.6 Current institutional catalog or electronic access.
1.7 Philosophy/mission and goals of the institution.
1.8 Vision and purpose for establishing a new nursing program.
1.9 Evidence of full institutional accreditation by the Commission on Colleges of the
Southern Association of Colleges and Schools, Mississippi Commission on College
Accreditation, and any other pertinent accrediting body.
1.10 Detailed description of educational, financial (to include budget), operational,
management, and physical resources to offer the proposed nursing education
program.
1.11 Sources for potential students and identification of any nursing programs within a
fifty-mile radius.
1.12 Data on potential qualified faculty.
1.13 Availability of supporting academic courses consistent with institutional
accreditation requirements and nursing program type.
1.14 Tentative timeline for the development and implementation of the nursing program,
to include the employment of a qualified nursing program administrator no less than
one year prior to the admission of students.
STAGE II - QUALIFY FOR INITIAL ACCREDITATION (permission to admit
students)
Process for Stage II Preparation
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
Following approval by the Board of Trustees to establish a new nursing program, the
institution shall contact the Director of Nursing Education regarding Stage II application
completion to include procedure, requirements, and due dates for the following:
a. Stage II progress report (APPENDIX J)
b. Stage II application and self-study report (APPENDIX K)
Criteria
The Stage II application and self-study report should include the following information:
2.1 Appointment of a qualified nursing education program administrator no less than one
year before the anticipated admission of students with vita included.
Criteria for Administrators for Mississippi Schools of Nursing:
2.1.1 Satisfy all other state specific requirements as outlined in Standard I.
2.1.2 Have a minimum of three (3) years of experience in a registered nursing
education program to include teaching, curriculum development, and
program evaluation.
2.1.3 Have leadership, management, and/or administrative experience in the
discipline of nursing.
2.2 Appointment of sufficient qualified nursing faculty members for the first full year of
operation no less than six months before the anticipated date for admission of
students.
For a pre-licensure nursing program the following shall apply:
2.2.1 Associate Degree Program. A minimum of four qualified fulltime faculty
members for an associate degree program. Each nurse faculty member shall
hold a current unencumbered license to practice as a registered nurse in
Mississippi and satisfy all other state specific requirements as outlined in
Standard II. Two or more faculty members employed must have teaching
experience in a nursing education program. At least one faculty member must
have documented competence and a minimum of one year clinical experience
in each of the following areas:
Adult Health Nursing
Maternal Child Nursing
Psychiatric /Mental Health Nursing
Competence is defined as academic and clinical preparation of faculty, which
includes degree specialization, specialty coursework, nationally recognized
certifications, or other preparation sufficient to address the major concepts
included in courses they will teach.
2.2.2 Baccalaureate Degree Program. A minimum of five qualified faculty
members for a baccalaureate degree program. Each nurse faculty member
shall hold a current unencumbered license to practice as a registered nurse in
Mississippi and satisfy all other state specific requirements as outlined in
Standard II. Three or more faculty members employed must have teaching
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
experience in a nursing education program. At least one faculty member
must have documented competence and a minimum of one year clinical
experience in each of the following areas:
Adult Health Nursing
Maternal Child Nursing
Psychiatric/Mental Health Nursing
Community /Public Health Nursing
Competence is defined as academic and clinical preparation of faculty, which
includes degree specialization, specialty coursework, nationally recognized
certifications, or other preparation sufficient to address the major concepts
included in courses they will teach.
2.2.3 Qualified faculty is defined as:
Master's or higher degree with a major in nursing and a major, clinical focus,
specialty or certification in adult health, maternal-child, psychiatric/mental
health, or community/public health nursing.
OR
Master's or higher degree with a major in nursing and at least five years
(within the last ten) of clinical and/or teaching experience in one of the
specified required areas of adult health, maternal-child, psychiatric/mental
health, or community/public health nursing (only one of the qualified faculty
for each program type may be employed meeting this criteria).
Must hold an unencumbered license to practice nursing in the state of
Mississippi (and other states, if applicable), satisfy all other state specific
requirements and meet all requirements of the affiliated clinical agencies.
Must satisfy a criminal history background check.
For a post-licensure nursing program the following shall apply:
2.2.4 Post-licensure Nursing Programs. The appointment of sufficient qualified
nursing faculty will be determined by the Director of Nursing Education and
AREC in accordance with type of program and national nursing specialty
organization, and standards for accreditation.
2.2.5 Qualified faculty is defined as:
Master's or higher degree with a major in nursing and a minimum of one year
of clinical experience as a registered nurse.
Must hold an unencumbered license to practice nursing in the state of
Mississippi (and other states, if applicable), satisfy all other state specific
requirements and meet all requirements of the affiliated clinical agencies.
Must satisfy a criminal history background check.
The majority of faculty in graduate nursing programs must also have
doctorates in nursing or a related field from regionally accredited institutions.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
2.3 Evidence that the nursing educational unit’s administrator and faculty have
developed the following:
2.3.1 Philosophy/mission, goals, and expected program outcomes for the nursing
educational unit that are congruent with those of the parent institution;
2.3.2 Course sequence of the nursing educational unit including general education
requirements and pre-requisites;
2.3.3 Overall curriculum, to include but not limited to:
2.3.3.1 Course descriptions, student learning outcomes for each course
including unit objectives, and learning activities for all courses;
2.3.3.2 Incorporation of established professional standards, guidelines, and
competencies;
2.3.3.3 Evaluation methodologies, which are varied and measure student
learning and program outcomes;
2.3.3.4 Practice learning environments that are appropriate to achieve student
learning and program outcomes;
2.3.4 Nursing program budget which has been approved by the institutional
process;
2.3.5 Organizational chart of the parent institution representing the relationship of
the nursing educational unit to the parent institution;
2.3.6 Admission, promotion, and graduation policies for the nursing educational
unit and justification if different from other institutional requirements;
2.3.7 Systematic plan of evaluation for the nursing educational unit to ensure
program effectiveness in fulfilling mission, goals, program and student
learning outcomes, reflective of national accreditation standards.
2.4 Provisions by the sponsoring institution for the following:
2.4.1 Adequate support services including but not limited to registrar, admissions,
testing, counseling etc.
2.4.2 The health and welfare of students;
2.4.3 Sufficient program and faculty support including but not limited to staff,
fiscal, physical, technological and learning resources;
2.4.4 Approved affiliation agreements with institutions and clinical practice
learning environments at which student learning will occur that:
- are legally binding agreements
- require completion of the clinical agency form (APPENDIX L)
- ensure faculty responsibility for students and student learning
experiences
- contain termination clauses
- provide for periodic review and revision as necessary;
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
2.4.5 Accreditation by a national and regional accrediting body approved by the
United States Department of Education.
Process Following Stage II Submission
See Roles, Responsibilities, and Procedure for Approval of a New Professional Nursing
Program (pp. 24-25).
2.5 The Peer Evaluation Review Team (PERT) will be appointed.
2.5.1 The PERT will evaluate the Stage II self-study report and make a site visit
according to the established time frame;
2.5.2 The PERT will submit a written report. ;
2.5.3 The report will be provided to the institution by the Director of Nursing
Education;
2.5.4 The institution may submit a written response to the report to the Director of
Nursing Education.
2.6 The Director of Nursing Education shall review the report, Stage II application and
self-study materials, and any written response from the institution.
2.6.2 The Director of Nursing Education and Office of Academic and Student
Affairs (OASA) shall review the recommendation of the PERT and prepare a
recommendation by OASA to submit to the IHL Board of Trustees for a final
decision.
2.6.3 Written notification of the IHL Board of Trustees’ decision regarding initial
accreditation shall be sent to the institution by the Director of Nursing
Education.
2.6.4 If accreditation is denied or deferred, recommendations relative to the areas
needing further development will accompany the notification and the
institution may reapply.
STAGE III - QUALIFY FOR FULL ACCREDITATION
Process
Once Initial Accreditation requirements have been satisfied, the following is necessary in
order to achieve Full Accreditation status (APPENDIX M):
3.1 A PERT shall be appointed and a site visit scheduled during the last semester of the
first class or in conjunction with the initial national nursing accreditation site visit.
3.2 The PERT report will be held until all graduates of the first class have taken the
NCLEX-RN®.
3.3 The Director of Nursing Education shall review the PERT site visit report, the
NCLEX-RN® pass rates of the first class, nurse practitioner certification pass rates,
nurse anesthetist certification pass rates, graduation completion rates, information on
graduate employment, and national nursing accreditation site visit report.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
3.4 The Director of Nursing Education and OASA shall prepare a recommendation by
OASA to submit to the IHL Board of Trustees for a final decision.
3.5 Written notification of the IHL Board of Trustees’ decision regarding full
accreditation shall be sent to the institution by the Director of Nursing Education.
3.6 If full accreditation is denied, reason for denial will accompany the notification. The
program must cease to admit students. Provisions will be made for closure of the
program (Closure of Nursing Program and Storage of Records, p. 12).
3.7 The program may apply for initial accreditation (Stage II – Qualify for Initial
Accreditation, pp. 19-22).
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
Roles, Responsibilities and Procedure for
Approval of a New Professional Nursing Program
I. Director of Nursing Education
The Director of Nursing Education serves within the IHL Office of Academic and
Student Affairs to administer the accreditation process for all Mississippi professional
nursing programs.
Duties related to new nursing program applications include the following:
1. Provide information to interested institutions regarding process and criteria.
2. Collect, edit, and distribute all materials submitted as part of the approval process.
3. Ensure that the process for public comment is carried out.
4. Work cooperatively with the Office of Academic and Student Affairs to prepare
appropriate materials and recommendations for consideration by the Board of
Trustees.
II. Institution seeking the establishment of a program of professional nursing
1. Follows Stage I process and criteria to obtain approval.
2. Following approval of Stage I -- follows Stage II process and criteria and submits the
required application and information.
3. Following approval of Stage II -- follows Stage III process and submits required
application and information.
4. Complies with all established time lines and due dates.
5. Stage II self-study report requirement -- provides the following:
a. Five (5) hard copies sent directly to the Director of Nursing Education;
b. Electronic copies of the self-study and required materials sent to the Director of
Nursing Education via email or flash drive for distribution.
6. Stage III information requirement -- submits application and required information on
NCLEX-RN® pass rates, nurse practitioner certification pass rates, nurse anesthetist
certification pass rates, graduation completion rates, graduate employment and
national nursing accreditation site visit report to the Director of Nursing Education.
7. Stage II and III site visits -- the nursing program administrator is responsible for the
following provisions:
a. Reimbursement to site visitors for expenses associated with housing, travel and
meals at the state rate;
b. Hotel reservations for site visitors;
c. Travel for site visitors from the hotel to the site and all intra-visit travel;
d. Agenda for the site visit sent to the PERT leader six weeks in advance for
approval;
e. Technology needs;
f. Communication with the Director of Nursing Education.
III. Peer Evaluation Review Team
The Peer Evaluation Review Team (PERT) is composed of nurse educators or
administrators who have completed a state site visitor training session. Site visitors are
27
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
appointed by the Director of Nursing Education and the Accreditation Review and
Evaluation Committee Chair based on geographic location and expertise. The PERT will
consist of two or more members, with one appointed as the team chair. The Director of
Nursing Education will participate on the PERT for initial and continuing ACEN and
CCNE visits.
PERT duties related to new nursing programs include the following:
1. Participate in a 2.5 to 3 day site visit.
2. Work as a team to clarify, verify, and amplify program materials as presented in the
self study.
3. Gather data and information for use by the IHL Board of Trustees to assess whether
the program is in compliance with the Criteria for Establishing a Professional Nursing
Program in the state of Mississippi, Stage II and III.
4. Submit a written site visit report of findings.
IV. IHL Board of Trustees
The Mississippi Board of Trustees of State Institutions of Higher Learning is empowered
and required by state statute with the sole authority to determine the
approval/accreditation status of a state nursing program.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
VI. REVISION DATES
July 1, 1992
July 1, 1993
April 1995-amended
June 1998-amended
July 1999-amended
November 2002
September 2004
November 2007
November 2009
September 2010
September 2011
July 2013
August 2013 – Edited official name change from NLNAC to ACEN & website page 37
December 2015
July 2017
October 2019-Edited only for educational requirements of administrators and faculty
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX A
Faculty Exception Form
BOARD OF TRUSTEES OF STATE
INSTITUTIONS OF HIGHER LEARNING
STATE OF MISSISSIPPI
Request for Faculty Exception requires prior approval for new and continuing faculty (fulltime, part-time, &
adjunct) and must be submitted to the IHL Director of Nursing Education at least two weeks before the beginning of
each semester prior to employment or prior to employment if hired during the semester. Employment of exception
faculty is contingent on being continuously enrolled and successfully completing the courses. Exception faculty
must report their inability to fulfill this obligation and will immediately be ineligible for employment. The form
should be submitted for faculty who have completed their degree the previous semester. A letter of decision will be
sent following review of the request and supporting documentation. New and continuing requests must include
supporting documentation with the form.
New Faculty Request:
❑ Official verification of enrollment in a graduate nursing program (Evidence: copy of letter of acceptance
from School of Nursing).
❑ Official verification (transcript) of course enrollment at beginning of each semester and at the end of each
semester indicating course completion (Evidence: transcript for previous semester showing successful
progression and transcript for current semester verifying continued enrollment).
❑ Official verification (transcript) of BSN degree (Evidence: transcript from university where degree was
conferred).
❑ RN-MSN requires submission of official verification from University/College of BSN level course
completion (Evidence: letter from School of Nursing Dean/Director).
❑ Verification of an unencumbered RN license to practice in Mississippi and another state, if appropriate
(Evidence: current copy of license verification form from Board of Nursing).
❑ Verification of a satisfactory criminal history background check (Evidence: copy of criminal history
background check document).
❑ Verification of date of employment (Evidence: copy of work schedule to include date of employment and
class/clinical assignments).
❑ Meet all other state specific requirements.
Continuing Faculty Request:
❑ Official verification (transcript) of course enrollment at beginning of each semester and at the end of each
semester indicating course completion (Evidence: transcript for previous semester showing successful
progression and transcript for current semester verifying continued enrollment).
❑ Verification of an unencumbered RN license to practice in Mississippi and another state, if appropriate
(Evidence: current copy of license verification form from Board of Nursing).
❑ Verification of date of employment for each semester (Evidence: copy of work schedule to include date of
employment and class/clinical assignments).
❑ Meet all other state specific requirements.
Submit Request for Faculty Exception form with all supporting documents by mail, FAX (601.432.6225), or email
([email protected]) to:
Dr. Janette S. McCrory
Director of Nursing Education
MS Institutions of Higher Learning
3825 Ridgewood Road
Jackson, Mississippi 39211
Revised October 2015
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
Request for Faculty Exception
Name of School of Nursing: _____________________________________________________
Semester: Fall ____ Spring: ____ Summer: ____ Year: 20__
Current Number & FTE of Employed Faculty: #: ______FTE:_____
Exception(s) Request: Name,
Credentials,
& License #
University/College
& Grad. Program
Currently Enrolled*
Degree Start &
Projected
Completion Date
FTE & Program:
ADN, BSN, MSN,
DNP, PhD
Type of Request
N=New or
C=Continue
Degree
Completed
Date
*Specify type of graduate program: RN-MSN; MSN; DNP; PhD; Other (list type). RN-MSN
requires submission of official verification from University/College of BSN level course
completion.
I understand that as the administrator of the unit in nursing, I am responsible for having the
required documentation for each approved new and continuing faculty exception available on
site at all times. I acknowledge that approval by the Director of Nursing Education is required
before employing the exception faculty each semester.
____________________________________________ ________________
Signature of Nursing Dean/Director Date
Revised October 2015
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX B
Request for Simulation Clinical Hours Form
BOARD OF TRUSTEES OF STATE
INSTITUTIONS OF HIGHER LEARNING
STATE OF MISSISSIPPI
Request for Simulation Clinical Hours from 26% up to 50% in substitution for traditional clinical hours in
each individual clinical course requires prior approval and must be submitted to the IHL Director of
Nursing Education at least three months prior to implementation date. A letter of decision will be sent
following review of the request, documentation, and outcome of site visit. Submit Request for Simulation
Clinical Hours and Focused Report through the secure site Deans and Directors Login
http://www.mississippi.edu/nursing/login/
Name of School of
Nursing:________________________________________________________________
Program
Type(s):___________________________________________________________________________
Proposed Implementation Date:
_______________________________________________________________
Accreditation Status:
• Mississippi Institutions of Higher Learning (IHL)
• Accreditation Commission for Education in Nursing (ACEN)
• Commission on Collegiate Nursing Education (CCNE)
• Commission on Accreditation of Nurse Anesthesia Educational Programs (COA)
• Southern Association of Colleges and Schools – Commission on Colleges (SACSCOC)
• Others/specify:
Clinical Courses Requesting Simulation Substitution Total
Clinical
Hours
Traditional
Clinical
Hours
Simulation
Clinical
Hours
___________________________________________________ ____________________________
Signature of Nursing Dean/Director Date
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX C
NCSBN Simulation Guidelines
BOARD OF TRUSTEES OF STATE
INSTITUTIONS OF HIGHER LEARNING
STATE OF MISSISSIPPI
Simulation Guidelines
Scope and Purpose
The following guidelines are meant to help: 1) boards of nursing (BONs) in evaluating the readiness of prelicensure nursing programs in using simulation as a substitute for traditional clinical experience; 2) nursing education programs in the establishment of evidence-based simulation
programs for the undergraduate nursing curriculum.
Definitions
Simulation: A technique, not a technology, to replace or amplify real experiences with guided experiences that evoke or replicate substantial
aspect of the real world in a fully interactive manner (Gaba, 2004). Traditional Clinical Experience: Practice in an inpatient, ambulatory care, or community setting where the student provides care to patients
under the guidance of an instructor or preceptor.
Guidelines Evidence Resources
There is commitment on the part of the school
for the simulation program. ⦁Letter of support from administrators stating
the program has their backing and will be
given the resources to sustain the program on
a long-term basis.
⦁Budgetary plan for sustainability and
ongoing faculty training is in place.
⦁Written short–term and long term objectives
for integrating simulation into the undergraduate curriculum and evaluating the
simulation program.
Program has appropriate facilities for
conducting simulation
⦁A description of the physical space for
conducting simulations including the lab,
storage/staging areas and a place for
debriefing.
Program has the educational and
technological resources and equipment to meet the intended objectives
⦁Program has a plan that describes the
simulation resources and equipment that will
be used to achieve the objectives.
See Scenario Resources Document
Lead faculty and sim lab personnel are qualified to conduct simulation.
⦁Submission of CVs and evidence of
qualifications such as: simulation conferences
attended, coursework on simulation instruction, certification in simulation
instruction, training by a consultant or
targeted work with an experienced mentor.
⦁SIRC Courses
⦁Simulation Preparation Programs
⦁ Webinars and presentations based on
INASCL Standards of Best Practice:
Simulation
⦁CHSE Certification
⦁Three-Step Program at Boise State
⦁Textbooks: Jeffries (2007) Simulations in
Nursing Education: From Conceptualization
to Evaluation; Jeffries (2013) Clinical Simulations: Advanced Concepts, Trends, and
Possibilities; and Palaganas, J.C., Maxworthy,
J.C., Epps, C. A., Mancini, M.E. (2015). Defining Excellence in Simulation Programs
Faculty are prepared to lead simulations. ⦁See NCSBN Simulation Faculty Preparation
Checklist
Program has an understanding of policies and
processes that are a part of the simulation experience.
⦁Policies describing the following, include,
but are not limited to: method of debriefing;
plan for orienting faculty; qualifications of
faculty and sim lab personnel; plan for training new faculty; evaluation methods.
⦁ Socratic Method of Debriefing
⦁See NCSBN Program Preparation Checklist
⦁INASCL Standards
Source: NCSBN Simulation Guidelines for Prelicensure Nursing Programs, October 2015, Volume 6/Issue 3 available from
www.journalofnursingregulation
33
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX D
NCSBN Faculty Preparation Checklist
BOARD OF TRUSTEES OF STATE
INSTITUTIONS OF HIGHER LEARNING
STATE OF MISSISSIPPI
Faculty Preparation Checklist
□ The simulation program is based on educational theories associated with simulation, such as
experiential learning theory.
□ The faculty members are prepared by following the INACSL Standards of Best Practice:
Simulation.
□ A tool for evaluating simulation-based learning experiences has been designed based on the
INASCL Standards of Best Practice: Simulation evaluation methods.
□ The program curriculum sets clear objectives and expected outcomes for each simulation-
based experience, which are communicated to students prior to each simulation activity.
□ The faculty members are prepared to create a learning environment that encourages active
learning, repetitive practice, and reflection and to provide appropriate support throughout
each activity.
□ The faculty members are prepared to use facilitation methods congruent with simulation
objectives/expected outcomes.
□ The program utilizes a standardized method of debriefing observed simulation using a Socratic
methodology.
□ A rubric has been developed to evaluate the students’ acquisition of KSAs (knowledge, skills,
and attitudes) throughout the program.
□ The program has established a method of sharing student performance with clinical faculty.
□ The program collects and retains evaluation data regarding the effectiveness of the facilitator.
□ The program collects and retains evaluation data regarding the effectiveness of the simulation
experience.
□ The program provides a means for faculty members to participate in simulation-related
professional development, such as webinars, conferences, journals, clubs, readings, and
certifications such as certified health care simulation educator (CHSE), and participation in
NLN Sim Leaders/Sigma Theta Tau International (STTI) Nurse Faculty Leadership Academy
(NFLA) with a focus on simulation.
Source: NCSBN Simulation Guidelines for Prelicensure Nursing Programs, October 2015, Volume 6/Issue 3
available from www.journalofnursingregulation
34
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX E
NCSBN Program Preparation Checklist
BOARD OF TRUSTEES OF STATE
INSTITUTIONS OF HIGHER LEARNING
STATE OF MISSISSIPPI
Program Preparation Checklist
□ The school has created a framework that provides adequate resources (fiscal, human, and
material) to support the simulation.
□ Policies and procedures are in place to ensure quality-consistent simulation experiences for the
students.
□ The simulation program has an adequate number of dedicated trained simulation faculty
members to support the learners in simulation-based experiences.
□ The program has job descriptions for simulation faculty members/facilitators.
□ The program has a plan for orienting simulation faculty members to their roles.
□ The program uses a needs assessment to determine what scenarios to use.
□ The simulation program provides subject-matter expertise for each scenario debriefing.
□ The program and faculty members incorporate the INACSL Standards of Best Practice:
Simulation.
□ The program has appropriate designated physical space for education, storage, and debriefing.
□ The faculty members have a process for identifying what equipment or relevant technologies
are needed for meeting program objectives.
□ The program has adequate equipment and supplies to create a realistic patient care
environment.
□ The faculty use evaluative feedback for quality improvement of the simulation program.
□ The administration has a long-range plan for anticipated use of simulation in the forthcoming
years.
Source: NCSBN Simulation Guidelines for Prelicensure Nursing Programs, October 2015, Volume 6/Issue 3
available from www.journalofnursingregulation
35
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX F
Calculation of NCLEX-RN® Pass Rates
Standard VI. 2.a. NCLEX Pass Rates: Annual NCLEX pass rates for all test takers (1st and
repeat) will be at 80 percent or above over a three-year period.
For reporting purposes, submit a copy of the NCLEX-RN® Pass Rate with calculations for the
calendar year to the Director of Nursing Education in January.
Calculation of NCLEX-RN® Pass Rates by Calendar Year
1. Use the December cumulative end of year report from the Board of Nursing (National
Council Licensure Examination report) to calculate pass rates for the calendar year.
2. Use the following formula to calculate the pass rate for your school of nursing.
3. Submit a copy of the pass rate with calculations in January.
Formula: b + c/a = NCLEX Pass Rate
a. ____ 1st writes during calendar year (CY) 20__
b. ____ 1st writes in 20__ who passed during same CY 20__
c. ____ 1st writes in 20__ who repeated (any # of times) and passed during same CY 20__
36
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX G
Calculation of Degree Completion Rates
Standard VI. 2.b. Degree Completion Rates: Expected levels of achievement for program
completion are determined by the faculty and reflect program demographics, academic
progression, program history, and best practices.
For reporting purposes, report the percentage of students within 150 percent of the stated
program length (the length of the program adjusted to begin with the first required nursing
course).
Calculation of Degree Completion Rate by End of Summer Term
1. Use the Exit Interview Form to track students’ reasons for non-completion
(APPENDIX H).
2. Count only students who did not graduate due to failure to meet program outcomes or
dismissal based on program policies and procedures.
3. Do not count students who left for personal reasons other than failure to meet
program outcomes or dismissal, such as change in major, relocation, health issues,
etc.
4. Undergraduate/Graduate Full-time Plan of Study
Example for 4 Semester Program
Class
Admitted
Graduate
in 150%
of Time
Class
Admitted
Graduate
in 150%
of Time
Class
Admitted
Graduate
in 150%
of Time
Spring
2012
Fall
2014
Summer
2011
Spring
2014
Fall
2011
Spring
2014
Spring
2013
Fall
2015
Summer
2012
Spring
2015
Fall
2012
Spring
2015
Spring
2014
Fall
2016
Summer
2013
Spring
2016
Fall
2013
Spring
2016
*4 semester program length @ 150% = 6 semesters
*Part-time plan of study would be calculated in the same manner @150% of total
time length of the program.
*Graduate programs – each school tracks 150% of the greatest length within the
cohort.
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX H
Exit Interview Form
MS Council of Deans and Directors of Schools of Nursing
Name (Optional)
Course Name and Number
Date
Exit Interview
1. Reason for Exit Interview: Academic Clinical Other List
2. Are you eligible to be readmitted? Yes No
3. What are your future plans?
Reapply to the nursing program
Change career goals List
Other
4. Check the factors listed below which played a role in your not continuing in the nursing program:
Academic factors
Reading comprehension Study skills
Science background Instructor/student conflict
Writing skills Math skills
Verbal skills Computer skills
Clinical performance Test taking skills
Other List
Personal factors
Personal illness/crisis
Time management
Other List
Family factors
Family illness/crisis
Child care
Other List
Work related factors
Worked too many hours List # of hours/week
Other List
Financial factors
No financial support
Limited financial support
Other List
5. Did you seek assistance from faculty/counselor for help with the above areas? Yes No
If no, was help available to you? Yes No
6. What could have been done to assist you in successfully completing this nursing program?
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Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX I
Board of Trustees of State Institutions of Higher Learning
Establishment of a Professional Nursing Program in the State of Mississippi
Nursing Program Application for
Stage I Declaration of Intent/Need
Legal name of
proposed school or program: ______________________________________________________
Address: ______________________________________________________________________
Legal name of
sponsoring institution
(University or College): __________________________________________________________
Address: ______________________________________________________________________
Name and title of chief
administrative officer
of sponsoring institution: _________________________________________________________
Agencies by which sponsoring
institution is accredited: __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Request for consultation with Board staff
Preferred dates for initial conference: _______________________________________________
Members of advisory committee and title and/or reason for representation on committee:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Professional sources consulted on feasibility of establishing program:
______________________________________________________________________________
______________________________________________________________________________
Required information is listed in the Mississippi Nursing Degree Programs Accreditation
Standards Procedure Manual entitled “Criteria for Establishing a Program of Professional
Nursing in the State of Mississippi” (http://www.mississippi.edu).
Attach additional pages as needed to provide support for Stage I Criteria.
39
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX J
Board of Trustees of State Institutions of Higher Learning
Establishment of a Professional Nursing Program in the State of Mississippi
Nursing Program Application for
Stage II Progress Report
Following permission to establish a new nursing program and prior to filing an application for
initial accreditation, the institution should seek consultation with the Director of Nursing
Education and shall file a progress report not less than six months before the planned date of the
opening of the unit in nursing. The Progress Report should address the program’s status in
meeting the requirements listed under Stage II in preparation for filing the application for Stage
II (Qualify for Initial Accreditation).
40
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX K
Board of Trustees of State Institutions of Higher Learning
Establishment of a Professional Nursing Program in the State of Mississippi
Nursing Program Application for
Stage II Qualify for Initial Accreditation
Application Process-The Stage II application form should be completed and accompanied by a
self study of supporting documentation addressing all Stage II criteria according to the
established time frame.
Official name of sponsoring institution ________________________________________
________________________________________________________________________
Address_________________________________________________________________
_______________________________________________________________________
Phone Number___________________________________________________________
This institution declares its intention to establish and conduct a nursing program in accordance
with the laws governing education in Mississippi and the standards, rules, and regulations
established by the Board of Trustees.
We understand that following review of Stage II materials and a site visit, a recommendation will
be made to the Board of Trustees regarding approval or disapproval of Stage II. A Board of
Trustees’ decision of approval will allow admission of students. A Board of Trustees’ decision of
disapproval will provide information on areas needing further development.
We also understand that, once initial accreditation is achieved, additional terms must be met
within an established time frame in order to achieve full accreditation.
Signature of President/Chief Institutional Officer__________________________________
Date______________________
41
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX L
Board of Trustees of State Institutions of Higher Learning
Establishment of a Professional Nursing Program in the State of Mississippi
Stage II Clinical Agency Form
Directions-Complete a separate form for each clinical agency.
Include a legally binding agreement with appropriate signatures for each selected agency that
• Ensures faculty responsibility for students and their learning experiences;
• Contains termination clauses;
• Provides for periodic review and revision as necessary.
Name of facility_______________________________________________________
Address______________________________________________________________
Phone number_________________________________________________________
Contact person_________________________________________________________
Accreditation___________________________________________________________
Services/clinical areas available____________________________________________
______________________________________________________________________
Type of Unit # of beds Average daily census # of students allowed
on unit
42
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX M
Board of Trustees of State Institutions of Higher Learning
Establishment of a Professional Nursing Program in the State of Mississippi
Nursing Program Application for
Stage III Qualify for Full Accreditation
This application should provide evidence that all National Accreditation Standards and State
Specific Requirements have been met.
A survey visit will be scheduled with the Director of Nursing Education and nursing
representatives during the last semester of the first year or in conjunction with the initial national
site visit. All prior recommendations must have been successfully addressed.
All materials and reports concerning the program will be reviewed and evaluated by the
Accreditation Review and Evaluation Committee. All accreditation standards must be met in
order to achieve the status of full accreditation.
The Director of Nursing Education will provide written feedback regarding accreditation status
to the school.
This institution has met all state accreditation standards and requests the classification of full
accreditation.
Official name and address of sponsoring institution and nursing program:
________________________________________________________________________
Signed: __________________________________________________________________
Title: ____________________________________________________________________
Date: ____________________________________________________________________
Information listed in Stage III of the "Criteria for Establishing a School of Professional Nursing
in the State of Mississippi" must accompany this application.
43
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX N
ACEN Procedure Manual
ACEN Accreditation Manual (2016). http://www.acenursing.net/manuals/Policies.pdf
44
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX O
CCNE Procedure Manual
Procedures for Accreditation of Baccalaureate and Graduate Degree Nursing Programs (2017).
http://www.aacn.nche.edu/ccne-accreditation/Procedures.pdf
45
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
APPENDIX P
COA Procedure Manual
Accreditation Policies and Procedure (2017). Council on Accreditation of Nurse Anesthesia
Educational Programs. http://home.coa.us.com/accreditation/Pages/Accreditation-Policies,-
Procedures-and-Standards.aspx
46
Board of Trustees of State Institutions of Higher Learning Nursing Program Accreditation Procedures October 2019
GLOSSARY
Competence - academic and clinical preparation of faculty, which includes degree
specialization, specialty coursework, nationally recognized certifications, or other preparation
sufficient to address the major concepts included in courses they will teach.
Degree Completion Rate - percentage of students who graduate within 150 percent of the stated
program length over a three-year period.
Graduate Degree Program – masters’ or clinical doctorate degree nursing program.
Non-Nurse Faculty – Non-nurses who are academically qualified and teach a nursing
course/clinical such as a dietician, pharmacologist, or physiologist.
Nurse Administrator – as defined by the institution and state accreditation standards, and may
include other program administrators, in addition to the Dean or Director.
Post-Graduate APRN Programs – A post-masters or post-doctoral certificate program that
prepares APRNs in one or more of the following roles: certified registered nurse anesthetist
(CRNA), certified nurse-midwife (CNM), clinical nurse specialist (CNS), and certified nurse
practitioner (CNP).
Simulation - An activity or event replicating clinical hours using scenarios, high fidelity
manikins, medium fidelity manikins, standardized patients, role playing, skills stations, and
computer-based critical thinking simulations (Hayden, Jefferies, Kardong-Edgren & Spector,
2009).
Traditional Clinical Experience – Practice in an inpatient, ambulatory care, or community
setting where the student provides care to patients under the guidance of an instructor or
preceptor (Alexander, et al., 2015).